Hemophilia of North Carolina

Since 1977, serving the people of North Carolina
affected by bleeding disorders.

260 Town Hall Dr., Suite A, Morrisville, NC 27560
1-800-990-5557 (toll free)

HNC Membership Application

 Join Us
Join HNC
 (*) Name(s):
 (*) Address:
 (*) City:  (*) State:  (*) Zip:
 Phone:  Home:  Cell:
 (*) Email:
 (*) Indicates required information
The following information is optional, but it will help us better serve you.
  Please check all that apply:
  I am a person with a bleeding disorder.
Type: (VIII, IX, vWD, etc.)
  I am a family member of a person with a bleeding disorder.
Relationship to me:
Type: (VIII, IX, vWD, etc.)
  I am a medical professional.
  I work in an industry providing products or services to persons with bleeding disorders.
Company name:
  None of the above, but I am interested in bleeding disorders and HNC activities.
Comments:
 

When you click on "Send Form" above, your information will be sent by email to HNC at info@hemophilia-nc.org. In a few days HNC staff will send a confirmation to the email address you specified above. Hemophilia of North Carolina will never share, give or sell your name, address or health-related information to any other organization, company or individual without your express permission.

If you prefer, you may download a printable Member Questionnaire* and return the completed form by mail or fax.

Return to the HNC membership information page.

(*Adobe Acrobat Reader is required.)